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• S ASSOCIATED LABORATORI# <br /> 806 North Batavia ■ Qrcmige CA 92868 h <br /> Chain of Custody Record Phone (7I4) 77I-6900 • Fox (714) 538-1209 <br /> Company j�, D r ^-� Pho eC� v�/^ 2��} A L Job No SQ) Z Z Page of <br /> Protect Manager K+[ `—�/ 'su� J n Faz V�� laS^ JO <br /> �+ ,� [ � Analysis Requested Test Instructions & Comments <br /> Protect Name �t4C� r© �� Prol # <br /> Sde Name 1 rsl(`f / <br /> and J 2 <br /> Address ccs. <br /> fb-Zsr <br /> v t' V -�W <br /> B <br /> Sample ID Lab ID Date Time Matrix Container Pres A <br /> Number/Size �-� <br /> 05 14. 0?- q:00 gi2- I T"t#e- dole <br /> 2 10 9p.� <br /> 3 �V ell -1 r� <br /> 4 1 .5-0 <br /> 5 �O <br /> rds <br /> E aJ JPO: <br /> 7 <br /> B <br /> 10 <br /> I <br /> 71 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Relinquished by 1 Rehngwshed by 2 Relinquished by 3 <br /> Sample Receipt-To Be Filled By Laboratory Sampler C� t-�$�A��v <br /> Total Number of Containers Properly Cooled Y/N/ A Signature Signature Signature <br /> Custody Seals Y 16A Samples IntY 114/NA Printed Name r J Panted Name Panted Name <br /> Received to Good Concittio Y/ Samples Acce Y IN pat (01 Time K:rs pate Time pate Time <br /> Turn Around Time Recehre � fo Received By 2 Received By 3 <br /> Signature Signature tognature <br /> Normal ❑ Rush ❑Same Day ❑48 hrs Printed Name Printed Name ��j -� Printed Name <br /> ❑24 hrs ❑72 hrs ryXIA <br /> Date Time Date f Time g Date Time <br /> Distnhution White Laboratory Canary Laboratory Pink Profect/Account Manager Goldenrod SampierlOnginstof Y`" <br />